Morton's Neurectomy Outcomes: Comparison of Plantar versus Dorsal Approaches

Transcription

1 Morton's Neurectomy Outcomes: Comparison of Plantar versus Dorsal Approaches Alexander Habashy, 1 MD, Gonzalo Sumarriva, 2 MBBS Robert Treu@ng, 1 MD March 18-19, Department of Orthopedics, Ochsner Clinic Founda@on, New Orleans, LA 2 The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans

2 Background: Morton s neuroma Compressive neuropathy of plantar digital nerve Cause: perineural fibrosis and interdigital nerve inflammation, exact etiology unknown Demographics: women 4 th or 5 th decades of life, also athletes late teens and twenties Location: 2 nd or 3 rd interspace

3 Background: Surgical Approaches Most common approaches: plantar longitudinal, plantar transverse, dorsal Dorsal: Technically easier, prevents painful scar formation on plantar foot, immediate weight bearing Disadvantages: requires adequate resection (at least 3 cm prox to intermetatarsal (IM) ligament) Complications: amputation or recurrent neuroma Plantar longitudinal: More direct exposure (n. lies superficial to IM ligament), typically reserved for recurrent neuromas Disadvantage: incision must avoid intermetatarsal space Complications: localized scar tenderness, plantar keratosis

4 Methods Query of EMR for ICD-9 code, pts cross-referenced with CPT code for Morton s neurectomy by one staff attending Timeframe: August 1995 to July 2004 Demographics: taken during EMR review Data: pts mailed and requested SF-36 and FFI Statistics: student t-test used to compare sub-categories and total scores of plantar and dorsal approach groups

5 Results 161 pts identified as receiving Morton s neurectomy Dorsal approach: 89 pts Plantar approach: 61 pts Both dorsal and plantar at different operative times: 11 pts Study group: 37 pts returned surveys Dorsal: 20 pts underwent 21 neurectomies Plantar: 17 pts underwent 21 neurectomies

6 Results Patient Demographics Dorsal Plantar n Age Demographics Male 2 (10%) 9 (53%) Female 18 (90%) 8 (47%) 1st Interspace 0 1 Neuroma Location 2nd Interspace 9 9 3rd Interspace 12 11

7 Results: SF-36 Summary P-value: 0.18, no stat significance difference between subgroups Dorsal Plantar Ave. Median Std. Dev Ave. Median Std. Dev p (0.05) Physical Functioning Role - Physical Bodily Pain Social Functioning Mental Health Role - Emotional Vitality General Health Composite Total SF

8 Results FFI Summary: Dorsal vs. Plantar Approach Dorsal FFI Average: (± 40.10) Plantar FFI Average: (± 38.51) P-value: 0.12 No statistically significant difference between subgroups Dorsal Pain Difficulty Time Total FFI Ave Med Std. Dev Plantar Ave Med Std. Dev p (0.05)

9 Discussion Literature: few reports directly compare dorsal and plantar incision for Morton s neuroma Nashi et al: prospectively compared 52 pts Dorsal: faster return to work, shorter hospital stay, better subjective satisfaction and fewer complications No statistical comparison or use of validated outcome assessments (eg. FFI or SF-36) between groups Wilson et al: 29 dorsal and 15 plantar pts Dorsal: 68% Sx resolution, 6 amputation neuromas Plantar: 100% Sx resolution, 2 painful scars Op time: min dorsal, 15 min plantar This study: only study to use SF-36 and FFI to compare dorsal and plantar approach

10 Conclusion Plantar longitudinal approach: in our opinion technically, historically fewer recurrent neuromas Results: no statistically significant difference between FFI and SF-36 scores Conclusion Plantar longitudinal approach for primary Morton s neurectomy may produce satisfactory results May use of either approach for Morton s neuroma Surgeon should choose approach most familiar and confident in performing

11 References Weinfeld, S., Myerson, M. lnterdigital neuritis: Diagnosis and treatment. J. Amer. Acad. Ortho. Surg. Vol. 4, No. 6, Nov/Dec, Amis J A, Siverhus SW, Liwnicz BH: An anatomic basis for recurrence after Morton s neuroma excision. Foot Ankle 1992;13: Richardson EG, Brotzman SB, Graves SC: The plantar incision for procedures involving the forefoot: An evaluation of one hundred and fifty incisions in one hundred and fifteen patients. J Bone Joint Surg Am 1993;75: Budiman-Mak, E., Conrad, K., Roach, K. The Foot Function Index: A measure of foot pain and disability. J Clin Epidemiol 1991;44(6); Kocher MS, Zurakowski D. Clinical epidemiology and biostatistics: A primer for orthopaedic surgeons. JBJS. Vol 86-A:no3, March Betts LO: Morton s metatarsalgia: Neuritis of the fourth digital nerve. Med J Aust 1940;1: Nissen KI: Plantar digital neuritis: Morton s metatarsalgia. J Bone Joint Surg Br 1948;30:84-94 Nashi M., Venkatachalam A.K., Muddu B.N.: Surgery of Morton s Neuroma: dorsal or plantar approach? J.R. Coll..Surg. Edinh., 42, Feb 1997, Wilson S, Kuwada GT. Retrospective study of the use of a plantar transverse incision versus a dorsal incision for excision of a neuroma. J Foot and Ankle Surgery. Vol 34, No 6, 1995,